UCONN Emergency Medicine Interest Group

Posts Tagged ‘cross-sectional study’

Journal Article Synopsis: Triage and High-Acuity Patients

In JOURNAL CLUB on September 2, 2011 at 7:00 AM

Summary of “Mandatory Triage Does Not Identify High-Acuity Patients Within Recommended Time Frames. ” Weber, Ellen J.; McAlpine, Ian; Grimes, Barbara. Annals of Emergency Medicine. Vol 58, Issue 2. Aug 2011. pp. 137-142

What is already known on this topic:
Structured triage is commonly thought to identify the most acutely ill walk-in patients. While there is mandatory triage at most US emergency rooms, there is currently no published data showing that is effective in recognizing the most high-acuity patients within timeframe targets. In England, triage (in the traditional sense) was abandoned, as it was thought to be more of a hindrance than a help.

What question this study addressed:
This study looked to see if the process of triaging identified the most acutely ill patients within the “appropriate” timeframe, as determined by the Emergency Severity Index (ESI). By ESI standards, level-1 walk-in patients should be treated by a physician upon arrival, and level-2 walk-in patients should be treated within 10 minutes.

What was the study design:
This was a retrospective cross-sectional study which took place over the course of one year. It examined time from arrival to treatment all ESI 1 or 2 walk-in patients in the ED of a US, urban, tertiary-care hospital with an annual census of 39,000 patients (15% of whom arrive via ambulance.) The majority of walk-in patients were subject to ESI 5-tier triage, unless they were in “emergency condition,” in which case they were taken immediately to a treatment room where triage was completed.

What this study adds to our knowledge:
The study examined data from one ED over the course of one year, and found that triaging resulted in prolonged triage times (greater than those proposed by the ESI). Less than half of high-acuity patients were seen within ten minutes of arrival to the ED. Overall, median interval time from triage to treatment was 12.3 minutes, with a range of 128 minutes, and a 95th percentile of 38.6 minutes. Three quarters of these high-acuity patients arrived during peak hours, during which time median interval time was 13.5 minutes.

How this is relevant to clinical practice:
ED clinicians count on triage to identify the most acutely ill patients within a reasonable timeframe. The effectiveness of triage should therefore be examined in light of its value to both patients and physicians. A large amount of resources, time, and staffing are necessary for triage practice. As hospitals are considering cost and benefit carefully, triage should be evaluated for its utility in meeting the goal of triaging patients within the recommended time-frame. If it is not working to the advantage of physician and patient, alternative approaches for providing care without unnecessary delays should be considered.

Other considerations:
Several innovations for patient intake are being considered for implementation in the US. Some ED’s fill patient rooms as patients arrive, however, this is not useful once rooms are full. Some ED’s have a physician or mid-level provider staffed specifically to help triage. In England, ambulance arrivals and high-acuity walk-ins are brought immediately to patient rooms. Others remain in the waiting area where they are treated in order of arrival. There is no formal triaging or taking of vitals, although nurses continually asses patients for possible accelerated need for treatment, including need for pain medication. With this system in place, more nurses are available to work within the treatment area.

Journal Article Synopsis: β-hCG, Ultrasound, and Ectopic Pregnancies

In JOURNAL CLUB on August 8, 2011 at 3:32 PM

Summary of “Use of a β-hCG Discriminatory Zone With Bedside Pelvic Ultrasonography” By Ralph Wang et al, Annals of Emergency Medicine vol 58: pp. 12-20. 2011.

What is already known on this topic:
Currently, pregnant women presenting to the ED with abdominal pain, vaginal bleeding, or syncope are assessed with pelvic ultrasonography and quantitative serum β-human chorionic gonadotropin (β-hCG) to rule out the possibility of an ectopic pregnancy. In 10-30% of these cases pelvic ultrasound is unable to reveal either an intrauterine (IUP) or ectopic pregnancy- an “indeterminate result”. A level of β-hCG above the “discriminatory zone” of 1500-3000 mIU/mL, in combination with an indeterminate ultrasound, has been shown to be associated with ectopic pregnancy.

What question this study addressed:
What is the utility of the β-hCG discriminatory zone in differentiating between ectopic and intrauterine pregnancies after an indeterminate bedside pelvic ultrasonography in symptomatic pregnant patients presenting to the ED?

What was the study design:
Cross-sectional study of 256 first-trimester pregnant patients presenting to ED with symptoms of abdominal pain or vaginal bleeding. All pelvic ultrasonography was performed by emergency physicians who were blinded to the patient’s β-hCG levels. Research assistants (blinded to the ultrasound results) contacted and performed a standardized interview with all enrolled patients at 8 weeks.

What this study adds to our knowledge:
A β-hCG cutoff of 3000 mIU/mL is not acceptable for use in clinical practice when attempting to identify ectopic pregnancy in symptomatic patients with an indeterminate result on bedside pelvic ultrasonography (sensitivity of 35% and specificity of 58%). On follow up, it was found that 65% of patients with an ectopic pregnancy have a β-hCG < 3000 mIU/mL.

How this is relevant to clinical practice:
When pelvic ultrasound is indeterminate for intrauterine pregnancy, serum β-hCG level alone does not differentiate intrauterine and ectopic pregnancy. A β-hCG cutoff of 3,000 mIU/mL will not aid with the exclusion of ectopic pregnancy and will cause 65% of cases to be missed.

Other considerations:
In the future the discriminatory zone of β-hCG must be re-evaluated. The bedside pelvic ultrasound can reliably exclude ectopic pregnancy only when they demonstrate a clear intrauterine pregnancy in symptomatic pregnant ED patients. Practitioners should avoid an inappropriate interpretation of β-hCG levels in patients without a clear diagnostic result.

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